Health

Individual Health Insurance Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

* Last Name

* First Name

Street Address

City

State

* Zip Code

* County

Phone Number

Alternate Telephone

* Email Address

Applicant / Family Member to be enrolled

Applicant Gender

Male

Female

Applicant height (example 5'8")

Applicant Weight (lbs.)

Applicant Birth Date

Applicant Tobacco Use

Yes

No

Spouse Gender

Male

Female

Spouse Height (example 5'8")

Spouse Weight (lbs.)

Spouse Birth Date

Spouse Tobacco Use

Yes

No

Child 1 Gender

Male

Female

Child 1 Height

Child 1 Weight

Child 1 Birth Date

Child 1 Tobacco Use

Yes

No

Child 2 Gender

Male

Female

Child 2 Height

Child 2 Weight

Child 2 Birth Date

Child 2 Tobacco Use

Yes

No

Child 3 Gender

Male

Female

Child 3 Height

Child 3 Weight

Child 3 Birth Date

Child 3 Tobacco Use

Yes

No

Child 4 Gender

Male

Female

Child 4 Height

Child 4 Weight

Child 4 Birth Date

Child 4 Tobacco Use

Yes

No

Any special requests or remarks?

Please let us know the best time to call and discuss your quote.

Morning

Afternoon

Evening

Anytime

Or Specify Other:

Before submitting, type in required validation security code: 5ca411

* Required Fields

West Penn Life & Health Inc.Promote Your Page Too
This web site may contain concepts that have legal, accounting and tax implications. It is not intended to provide legal, accounting or tax advice. You may wish to consult a competent attorney, tax advisor, or accountant.